Catastrophising and (maybe) what to do about it for subacute/chronic pain

This post is written primarily for non-psychologists, like a few of my recent ones! This is because I think it’s vital that we avoid ring-fencing aspects of pain management by various health professions, and recognise that without a team approach, people with chronic pain will slip through the gaps and not get effective treatment. And because psychological research informs practice across the health professional spectrum and it’s time we got well-informed and much more confident. Right, end of soapbox moment and back to writing!

Catastrophising is the tendency to “think the worst” about a given situation, or a potential situation. (here’s a nice discussion about it on Psych Central). While it’s something that many of us can do in certain circumstances (especially after a sudden unexpected event like an earthquake!), it has increasingly been a focus of research looking at the factors that influence difficulty recovering from acute pain and complicating disability associated with chronic pain management.

Catastrophising is one vulnerability factor included in the pain anxiety and avoidance model (“fear avoidance model”). It’s thought to influence the appraisal or judgement a person makes about the pain, increasing anxiety and activating the escape or avoidance tendency. Avoiding the movements that produce or influence pain (or it is anticipated might do), or activate the belief that the person “can’t cope” with the movement, or the pain – or any other dire prediction will occur (like bone rubbing on bone, or joints being unstable …) reinforces avoidance and the belief in the negative consequences via negative reinforcement. In other words, by not doing the movement, the feared consequences don’t happen, and so the decision to avoid is strengthened.

How do you know whether someone is tending to catastrophise? Well, astute clinicians will be listening to words the person they’re working with is saying, and trying to understand what the person thinks is going on when they move or experience pain. Things like “I think the pain will be too much”, “My joints are grinding and clunking”, “The doctor said I will end up in a wheelchair”, or similar! There are also several assessments that can help. The Pain Catastrophising Scale is one that is particularly helpful, but also the Fear of Pain Questionnaire (here’s a link to a reference), and the catastrophising subscale of the Coping Strategies Questionnaire (link to a reference for it is here) can also be used.

What do you do then? While for some people with reasonably low levels of catastrophising, it’s relatively easy to begin to encourage them to carry out activities they’ve been avoiding, for others it’s helpful to use a more formal approach such as graded exposure (here’s a link to one of my previous posts about exposure treatment). One study, however, found that people with moderate and lower levels of catastrophising benefited from this approach, while people with higher levels of catastrophising didn’t respond so well (Flink, Boersma & Linton, 2010).

Interestingly a study by Ong, Zautra and Reid (2010) found that there is a relationship between experiencing positive emotions and rebounding from pain fluctuations – and people who were found to be resilient modified their tendency towards catastrophising by doing things that made them feel good.

This study is also an excellent one for looking at process, or how people change over time using a daily diary method.

The finding in this paper suggests that one way for helping people be more resilient and modify their tendency towards catastrophising might be to help them identify and then pursue positive experiences during each day. Scheduling pleasant or enjoyable events as part of a daily routine is certainly something any clinician can do, and often those pleasant events can be physical, such as going for a walk, playing with the kids, or even doing some stretches.

Finally (but not the final word!), a study by McKnight and colleagues looked at the mediating effect of self efficacy on the relationship between catastrophising and disability. In this study, participants with early osteoarthritis in the knee were given either self management, exercise or a combination of both. The researchers were particularly interested in whether focusing on a positive aspect (self efficacy) or a negative aspect (catastrophising) had the greatest influence on outcome (disability), and whether a combination of both had a larger effect.

The hypotheses were that catastrophising and self efficacy have a negative correlation, catastrophising and function have a negative relationship, and self efficacy and function have a positive relationship. In other words, the relationship between catastrophising and function would be mediated, or influenced, by self efficacy.

What they found was that catastrophising does directly affect disability (loss of function), but that it is mediated in part by self efficacy. What this means from a practical, clinical point of view, is that it’s really important to target both self efficacy and catastrophising. How to do this as a nonpsychologist means (IMHO!) the following:

Treatments targeting cognitive reappraisal seem to influence catastrophising most effectively. This means helping people to view pain fluctuations as a normal part of returning to movement or exercise. It might mean using a description like “your body needs to get used to moving again”, and reminding people that their pain often fluctuations up and down and never remains at an extreme forever.

Mindfulness approaches seem to be very helpful for people to learn to accept or “live alongside” their pain, thus reducing catastrophising. This might translate into encouraging people to really be aware of the range of sensations that are concurrent when pain is present. So, asking the person to focus attention on pressure, texture, temperature, and other sensory modalities like smell or taste as well as their pain can help them to be accept the sensations without judging them.

Treatments that increase self efficacy are very effective – such as generating a baseline level of activity, and sticking with it so as to be aware that it’s possible to still do something even when sore; asking what the person actually did in detail even when sore is helpful to remind the person that they’re not ‘back at square one’ even during a flare up. Setting achievable actions (rather than goals that may depend on a lot of things going well) is helpful, as is ensuring goals are reviewed often – and counting the number of actions carried out rather than the number of times the weren’t done.